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Editor’s note: This column was inspired by a real case, and the responses of the team members have been written by the editors of the column as an example of how the interdisciplinary team (IDT) can contribute to comprehensive, person-centered care.
Coordinating a televisit with input from the IDT is challenging and requires coordination and communication with multiple individuals.
Mrs. R is a 96-year-old Caucasian woman living with dementia, who exhibits behavioral and psychological symptoms such as verbal abuse directed to staff and hitting staff if she does not like what they are asking her to do. She has comorbid diagnoses of degenerative joint disease, sick sinus syndrome with pacemaker insertion 10 years ago, paroxysmal atrial fibrillation, hyperlipidemia, colonic diverticulosis, and a history of falls with multiple fractures, including right and left clavicular fractures and right tibia and fibula fractures. There have been no falls for the past year. She ambulates short distances in her room with contact guard and a walker but uses a wheelchair for longer distance ambulation.
Her current medications include aspirin, 81 mg daily; risperidone, 0.25 mg twice a day; vitamin D, 2,000 units daily; metoprolol ER, 50 mg daily; calcium carbonate, 1,500 mg twice a day; lisinopril, 30 mg daily; lovastatin, 20 mg daily; and sertraline, 50 mg daily. Her most recent laboratory results, including a complete blood count and comprehensive metabolic panel, were all within normal limits. Her most recent vital signs were blood pressure 108/65, heart rate 65 beats per minute, respiratory rate 12 breaths per minute, temperature 96.7°F, and pulse oximetry 92%. She has lost five pounds over the past 2.5 months since the initiation of the quarantine for COVID-19.
Telehealth visits can be more time consuming and complicated than face-to-face visits, which may limit interaction between IDT members. The staff may consider strategizing how best to maximize communication among the IDT members, between the IDT and providers, and ultimately with the resident and family. Ideally, such communication would take place before the telehealth visit with the resident and physician. If a virtual meeting of the entire IDT is not feasible, perhaps there could be a point person who interacts with each provider to share pertinent information from IDT members.
The attending physician found the input from the IDT during this telehealth visit was invaluable in helping to describe the current status of the resident, which led to the development of a plan of care that was realistic and would hopefully optimize her quality of life.
The attending physician spoke with the resident’s son about decreasing the risperidone dosage to 0.25 mg at bedtime, stopping the vitamin D, calcium, and statin, and monitoring those changes. She also discussed the risks of a person with dementia taking an antipsychotic and the goal of eventual discontinuation.
The dietician informed the attending physician that the staff are collaborating to ensure Mrs. R’s food preferences are honored and are continuing to monitor her weight and intake. She will also resume the happy hour activity and more communal dining options, when available, to maximize her socialization.
The nursing team informed the attending physician that they would monitor her sleep and behavioral symptoms and notify the provider if there are significant changes.
The activities staff and social worker informed the attending physician that they would continue to facilitate interactions with her son via the phone and video platforms that are the most useful for her, and they would encourage her physical activity in her room. Additionally, the social worker would incorporate strength and resilience strategies into the plan of care and coach the staff on how to weave this information into their time with Mrs. R.
During a telehealth visit, conducted with the help of a nurse, the attending physician was very concerned about the weight loss and observed that Mrs. R had dry lips, perhaps due to dehydration. She considered getting STAT labs and starting intravenous fluid (with the son’s consent). Although that treatment order would address the acute presentation of possible dehydration, it would not address the underlying cause of the symptom. The attending physician decided to collaborate with members of the IDT to get more robust information. She coordinated HIPAA-protected emails and/or calls with the nurse, nursing assistant, social worker, activities director, dietician, and consultant pharmacist to get their input.
The nursing assistant informed the attending physician that Mrs. R prefers to sleep until late morning and then enjoys a brunch meal; she then has dinner at the usual time. Mrs. R has been noticed to be sleepier in the late afternoon around dinnertime, which may be contributing to her poor appetite. She declines several meals per week, but she will accept some nutritional supplements and really enjoys sandwiches. Before the quarantine, Mrs. R’s son had shared meals with her a few times a week, an activity she really enjoyed. The staff believe she misses her son, and the virtual visits have been challenging given her poor vision and hearing.
The pharmacist recommended discontinuing any medication not considered essential during the COVID-19 quarantine, which included vitamin D, calcium carbonate, and lovastatin. Discontinuing medications that offer little value and impact simplifies medication passes, which is beneficial to both the resident and the nursing staff. The pharmacist also recommended titrating the risperidone to one dose in the evening to see if Mrs. R becomes more alert during the day with an improvement in her appetite. The staff will need to monitor for behavioral symptoms and changes in Mrs. R’s appetite. With her current blood pressure measurement, decreasing the metoprolol may also be an option.
Mrs. R typically prefers independent activities, but she enjoyed attending the weekly social hour with cocktails and would bring her son. Despite challenges with hearing and vision during Mrs. R’s virtual meetings with her son, the activities associates continue to facilitate these visits. These still provide the best possible alternative to face-to-face meetings. Mrs. R has a mobile phone, but the display is small and makes telehealth visits more difficult. As an alternative, the staff have used a larger tablet device to offer a better image of her son. With the use of headphones that her son purchased for her, the visits with Mrs. R have become a little more interactive. Additionally, the activities staff have been encouraging Mrs. R to listen to her favorite music on her iPod while she does in-room exercises such as sit-to-stands, marching in place, and walking around her room.
The social worker has also been coordinating virtual visits with the son and has tried to minimize Mrs. R’s distress and confusion at not having in-person visits. Mrs. R likes to reminisce about her memories of married life and raising a family. The social worker has spoken with Mrs. R’s son about the changes in his mom’s eating and sleeping habits as well as concerns about the stress caused by the quarantine. The son shared that his mom endured difficult experiences in her life, and he offered some insight into how she overcame those crises. For example, she worked in a high-stress corporate position and routinely had to manage complex employee and community relations. One of her coping strategies is to use humor, and she particularly enjoys the style of Steve Martin. The social worker also engaged the son in a discussion of advance care planning issues and clarified his wishes should his mom become ill enough to require hospitalization. It was clarified that Mrs. R’s code status is do-not-resuscitate (DNR).
The nurse informed the attending physician that Mrs. R has not had any aggressive behaviors over the past few months during quarantine and that she participates with her morning and evening care routines. She remains quietly in her room and does not demonstrate distress at being in the same environment every day. She frequently asks why her son does not visit. The nurse noted Mrs. R’s increased sleepiness, consistent with the nursing assistant report, and perhaps related to the second dose of risperidone. The nurse also noted that Mrs. R had no falls in the past year.
The dietician met with Mrs. R, and together they worked out a plan that includes more sandwiches, and yogurt and toast for brunch. The staff will continue offering her a supplement between meals; as soon as the happy hour event resumes, she will be invited to that activity. The facility is discussing reopening the dining room while still maintaining social distancing, which may also help with her appetite. The staff is to encourage her to drink fluids and continue to monitor her weight.
Dr. Resnick is the Sonya Ziporkin Gershowitz Chair in Gerontology at the University of Maryland School of Nursing in Baltimore. She is also a member of the Editorial Advisory Board for Caring for the Ages.
Ms. Hector is a clinical educator and professional speaker specializing in clinical operations for the interdisciplinary team, process improvement and statistical theory, risk management and end-of-life care, and palliative care, among other topics. She is a member of the Editorial Advisory Board for Caring for the Ages. She is passionate about nursing homes and supporting staff to care for the most vulnerable people in their communities.